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Medical Care for People in Transition: Symptoms May Point to Stories

It's easy, when justifying the care of immigrants, refugees and the "unnoticed," to go back to the writings of our faith tradition. We have the Old Testament histories of wandering and the exhortations to take special care of the refugee. We have the Sermon on the Mount and the story of the sheep and the goats in Matthew 25. We have Rerum Novarum, with its request for "especial consideration" of the poor, and the opening paragraph of Gaudium et Spes that identifies "the joys and the hopes, the griefs and the anxieties" of the poor and afflicted as the "joys and hopes, the griefs and anxieties of the followers of Christ."

What we really have, though, are stories. We have the story of the prodigal son, who, probably without knowing it, experiences love from his father. We have the story of the widow's mite, and of others who gave freely of their possessions and their lives. And, when we sit and listen, we hear the stories of the people moving and living among us.

The medical care of the immigrant and refugee brings special difficulties. We will be challenged with unfamiliar diseases, languages and customs. If we are lucky, we will hear their stories, the stories of those who are wandering, those in exile, those searching to build a new life.

Each of the three patients below illustrates puzzles and opportunities that accompany medical care of adoptees, immigrants and refugees. These patients can challenge us as physicians; if we pause, they can give us the gift of their story.

INTERNATIONAL ADOPTEES AND FAMILIES

The Case: A 10-year old girl had been recently adopted from Eastern Europe and was having a difficult transition. Part of her problem was smelly and frequent loose bowel movements she continued to have, even with a mild diet. When she came to the clinic that specialized in children who had been adopted from overseas, stool cultures and ova and parasite exams were sent to the laboratory. Her stool was full of parasites.

Discussion: About 10,000 children come to the U.S. each year to be adopted. Slightly more than half are girls, and slightly more than half are between the ages of 1 and 4 years old. The countries of origin shift from year to year, but China, Russia, Ethiopia and South Korea have been common home countries. There has been much recent focus in the media about some of the behavioral, developmental and health challenges these children and their adoptive families have. Many medical centers have established clinics specializing in the care of the child adopted from overseas. These clinics typically offer the initial medical exam children need after arrival, and many are able to assist with medical, behavioral and developmental problems that may emerge.

The focus needs to be not only on the child, but also on the adoptive parents travelling to the country of origin, extended family members including siblings and grandparents who will be close to the child, and any caregivers who work with the family. The adopted children are frequently under-immunized, and they routinely have been exposed to unclean food and water and crowded living situations. They can have an increased risk of measles, hepatitis A, hepatitis B and other infectious diseases not usually seen in the United States.

Before adoptive parents and other family members travel to bring the child home, they should prepare for infections and other diseases they could encounter in while travelling. A travel clinic can provide immunizations and medication, as well as advice about food safety and prevention of malaria and diarrhea. Family members and caregivers who will spend time with the child from overseas should be immunized or otherwise protected against Hepatitis A, Hepatitis B, and measles. Other immunizations should also be up to date, including tetanus, diphtheria and pertussis.

Even though adopted children, like all immigrants, receive a medical exam in their country of origin before arriving in the U.S., the point of the exam is to detect contagious diseases, like tuberculosis, that could make the child ineligible for a visa. The medical examination is not intended to detect behavioral or developmental delays, or other illnesses not severe enough to disqualify the child from receiving a visa. A complete examination in the United States will include a history and physical examination as well as screening for developmental delay.

Follow-up: The 10-year-old girl with diarrhea was tested for bacteria, viruses, and parasites. Examination of her stool under the microscope showed that she had three parasites, one of which is known to cause the frequent and foul-smelling stools she had been experiencing. Treatment with antiparasitic drugs has begun.

About three-fourths of all children adopted from overseas will have intestinal parasites. It is typical that if people have parasites, they usually have more than one parasite because of their continual exposure to unclean water or unhygienically prepared food. Parents should know that multiple early morning stool specimens might need to be collected over a few days before parasites can be identified.

PROTECTING PUBLIC HEALTH

The Case: The call came from the emergency room. The physician was seeing a patient who had arrived at O'Hare Airport and taken a cab straight to the hospital. The patient did not appear ill but had flown to Chicago from an Asian country because he was being treated for tuberculosis and didn't think he was getting better. He had heard of the hospital in Chicago from TV shows and decided he needed to get himself there for better treatment.

The ER physician and I left our common nightmare unspoken: that a patient with active tuberculosis, possibly partially treated and drug-resistant, had been on airplanes for the better part of a day. It could be a public health disaster.

The patient was immediately put into an isolation room so that the ventilation outflow would not recirculate into the rest of the hospital; all who entered now wore masks.

Discussion: The concept of isolating ill persons goes back at least to Old Testament times. As described by Paul Sedhev, there are references in both Leviticus (13:46) and Numbers (5:1-4) that those with leprosy or other skin diseases should be expelled from camp and live separately.1

"Isolation" and "'quarantine" are sometimes used interchangeably, but there are important distinctions between the two words. "Isolation" is used to separate the sick from the well; "quarantine" is used to separate and restrict the movement of those who may have been exposed to an infectious disease. "Quarantine" evolved in the 14th century from efforts to protect healthy persons from the plague (the Black Death). Cities in both Italy and modern day Croatia started by isolating ill people outside the city walls. When that was not effective in stopping the spread of disease, the Great Council of Ragusa (now Dubrovnik, Croatia) decreed that all citizens or visitors arriving from plague-endemic regions would have to wait for 30 days before entering, to see if they carried the disease. This practice of restricting the movement of seemingly healthy visitors spread to Italy and the time was increased to 40 days, quaranta giorni, the origin of our word "quarantine."2

All immigrants and refugees who want to enter the United States are tested in their home countries for communicable diseases, including tuberculosis, that could endanger the public health in the United States. These tests are not perfect, and even with a chest X-ray, tuberculosis can be missed. The CDC now maintains quarantine stations at major airports and other points of entry. The medical staff in these stations decides if ill persons can enter the United States; they also have the power to quarantine healthy persons who may have been exposed to tuberculosis or influenza capable of causing a pandemic.3

Despite a system of overseas health examinations and quarantine stations at 20 points of entry, contagious diseases will not always be apparent in those coming to the United States. Because the focus of the overseas medical examination is on a small number of contagious diseases which could affect public health in the United States, it is important that refugees and immigrants have thorough medical examinations as soon as possible after arrival which are broader in scope and have the purpose of helping the patient, rather than excluding them from entry.

Follow-up: Numerous sputum specimens were collected from the patient from central Asia. He did have tuberculosis; it was sensitive to drugs commonly used to treat the infection; his infection was controlled enough so that he was not considered to be contagious to those who sat near him on the airplane.

TRAUMA AND TORTURE

The Case: The call came from the frozen section room. A piece of skin didn't have the expected cancer under the microscope, and the pathologist was concerned that he was looking at an infection rather than a cancer. The cluster of cells looked like the clusters of cells seen in tuberculosis. As everyone put on a mask, the resident looked up the patient's diagnosis in the computer and saw the patient was admitted for removal of a skin mass, assumed to be cancer. The woman had lived in Philadelphia for a long time, and there was no travel history or reason to suspect she had been exposed to tuberculosis.

Within two days, we were able to say that the skin mass was from tuberculosis and not cancer. After the patient heard the "good news," she started wailing, "Not TB! Not TB!"

The blue number tattooed on her forearm explained all. She was a concentration camp survivor, and the diagnosis of tuberculosis brought back memories that overwhelmed her.

Discussion: All refugees who come to the United States suffer in some way from loss and trauma. Refugees ages 16 and over should all be screened after arrival for symptoms of depression and post traumatic stress disorder (PTSD). Symptoms of PTSD can be characterized as re-experiencing, avoidance and hyperarousal. Refugees may not be able or willing to discuss symptoms at the initial screening. If a refugee is from a country with a stigma against mental health support, the mental health symptoms may express themselves as physical symptoms such as headaches, backaches or stomachaches. These symptoms can also emerge months or years after arrival.

All refugees have experienced suffering, but those who have been tortured can be referred to centers specializing in their care and rehabilitation. The Marjorie Kovler Center in Chicago is an a example of an organization that attempts to meet the medical, mental and social needs of those who have been tortured, with an aim of helping the refugee to trust others again.

Follow-up: Treatment was begun for her tuberculosis.

All of our patients have a history, but when they come to us as immigrants or have fled from somewhere as refugees, their stories are particularly rich, inspiring and humbling. We are privileged when we can help these travelers, and even more so when they share their stories with us.

KATHLEEN G. BEAVIS is a pathologist and director of the microbiology and immunology laboratories at University of Chicago Medicine, Chicago. She wishes to thank Helen M. Gleason and Katherine H. Beavis for their suggestions and critical reading of this article.